The following was received from the Commonwealth of
Virginia (the Agency) via email:
On December 1, 2021 at 0525 EST, the Virginia Radioactive Materials Program (RMP) received a report from the licensee that a medical event involving Yttrium-90 microspheres occurred on 11/30/2021 (procedure date). According to the written directive, the prescribed dose to the right liver (treatment site) was 27.6 millicuries (mCi). The procedure was interrupted due to the artery spasm, which could not be identified before the treatment began and as a result, only 14.5 mCi of the prescribed dosage was delivered to the treatment site (right liver). The administered dosage was estimated to be 47% less than the prescribed dose. According to the licensee's preliminary report, no healthy tissue or organ other than the treatment site was exposed because of this event and the patient was notified. The RMP will schedule to investigate the event and this report will be updated when the final investigation report is available.
Virginia Event Report ID No.: VA210008
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
- * * RETRACTION ON 12/09/21 AT 1555 EST FROM ASFAW FENTA TO KAREN COTTON-GROSS * * *
The following retraction was received via email from VA; RMP:
On December 6, 2021, the RMP investigated the case and determined that the procedure was terminated due to emergent patient conditions (artery spasm). The licensee revised the written directive within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> after the termination of the procedure. This incident did not meet the criteria of medical event reporting. [RMP] requests to retract this report.
Notified R1DO (Dentel) and
NMSS Events Notifications via email.